Emergency Airway Management Part 1: Optimizing the basics

An approach to the initial airway management of emergency department patients

Case

A 55 year old man was found unconscious in the bathroom by his family. He has a GCS of 7. His vital signs are a heart rate of 130, a blood pressure of 90/55, a respiratory rate of 28, and an oxygen saturation of 89% on room air. He is lying flat on the resuscitation stretcher and making some sonorous breath sounds. You resident grabs a laryngoscope and says, “ABCs… let’s get this guy intubated”…

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Chloral Hydrate Toxicity

A guide to the first 10 minutes of resuscitation in chloral hydrate toxicity

Case

#1 A 4 year old girl was prescribed chloral hydrate to be taken at home prior to a procedure by her dentist. After a successful procedure, she was monitored for 1 hour, at which point she was described as tired but rousable and she was discharged home. Three hours later her mother finds her unresponsive and calls 911. Paramedics arrive to find a child in respiratory arrest and quickly package her up for the 5 minute drive to your small community hospital… (Nordt 2014)

#2 Later that evening, a 21 old man is transported from a local bar unresponsive after drinking a beer. The monitor reveals a wide complex tachycardia. There is a faint odor of pears on his breath, which triggers a vague recollection from medical trivia night. You have a nurse talk to his friends, and sure enough, they admit to slipping him a “Micky Finn” as a prank…

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Performance Under Pressure

How well do you perform when the pressure is high? This is one of my favorite emergency medicine topics. Emergency personnel pride themselves on thriving under pressure. Doctors like to think of themselves as perfect, maybe even god-like. Combine the two, and you can imagine the ego of the average emergency physician. But underneath all that bravado, we are all human. We all experience stress, and we all respond to stress in distinctly human ways.

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Torsades de Pointes

The first 10 minutes of emergency medicine resuscitation of torsades de pointes

Case

A 46 year old female is referred into the emergency department after multiple syncopal episodes. Her family physician did blood work and found her to be hypokalemic. She is on venlafaxine for depression and amitriptyline for sciatica. She is currently on a course of moxifloxacin for her sinusitis and this morning took a dose of fluconazole for the resultant candidiasis. On arrival, she is alert and looks well. However, as the ECG is being performed, she slumps over and you see:

ECG52105_3_hypoK.jpg

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Thyroid storm

The emergency department management of severe, decompensated hyperthyroidism

Case

A 45 year old woman with a past medical history of hyperthyroidism is brought into the emergency department by her partner. She has had urinary tract symptoms for the last 2 days, but now she looks really sick. She has been having diarrhea and crampy abdominal pain. She is having a hard time concentrating, is tremulous, and drenched in sweat. Her vital signs at triage include an irregular heart rate of 142 and a temperature of 39.5 degrees celsius. Continue reading “Thyroid storm”

Resuscitation of the crashing infant

An approach the the initial resuscitation of the critically ill child

Case

It is your last of 3 night shifts, but so far it has been great. You successfully resuscitated a woman with severe postpartum hemorrhage. You got ROSC on a young cardiac arrest patient, and just heard that he is awake and talking after having his LAD opened in the cath lab. You even managed to get the Cunningham technique to work on a dislocated shoulder for the first time in your career. Now, during a lull, you are joking with the nurses, and someone says the work “quiet”. The next minute, the triage nurses is running down the hallway with a limp, blue 3 week infant in her arms and 2 very scared parents in tow…

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Emergent Cardiac Pacing

How to set up emergency cardiac pacing

Case

The 67 year old bradycardic patient from the previous case has a heart rate of 38 and a blood pressure of 68/45. It is time to start pacing… Continue reading “Emergent Cardiac Pacing”